Brustoperationen bei Geschlechtsinkongruenz/-dysphorie: Eine Übersichtsarbeit in Analogie zur aktuellen Literatur und der neuen S2k-Leitlinie – Brustmaskulinisierung/-neutralisierung und Brustaufbau bei transidenten und nicht-binären Personen

Zusammenfassung

Hintergrund

„Top Surgery“, d. h. geschlechtsmodifizierende Eingriffe am Oberkörper, gehören zu den häufigsten Operationen bei Geschlechtsinkongruenz (GI). Diese Eingriffe umfassen brustaufbauende oder brustmaskulinisierende/-neutralisierende Eingriffe und zielen darauf ab, das körperliche Erscheinungsbild an die Geschlechtsidentität anzupassen. Die Übersichtsarbeit orientiert sich an der neuen S2k-Leitlinie „Chirurgische Maßnahmen bei Geschlechtsinkongruenz“ und gibt einen Überblick über die aktuellen brustchirurgischen Techniken und die dazugehörige Literatur.

Patient:innen/Material und Methoden

Es erfolgte eine Literaturanalyse basierend auf Daten aus PubMed von 1973 bis Juli 2024. Die Analyse umfasste 122 Studien zu körpermodifizierenden Brustoperationen bei Personen mit GI. Dabei wurden die Kernaussagen extrahiert und zusammengefasst.

Ergebnisse

Körpermodifizierende Brustoperationen (brustaufbauend bzw. brustmaskulinisierend/-neutralisierend führen in der Regel zu einer signifikanten Verbesserung des Wohlbefindens der Betroffenen. Brustvergrößerungen werden meist mit Silikonimplantaten oder Eigenfetttransplantationen durchgeführt, wobei letzteres oft mehrere Eingriffe erfordert. Mastektomien zielen darauf ab, den Oberkörper zu maskulinisieren bzw. zu neutralisieren und möglichst die Sensibilität der Brustwarzen zu erhalten. Die Wahl der Operationstechnik hängt stark von der Brustgröße, dem Grad der Mastoptose und der Hautelastizität ab. Die Zufriedenheit der Behandlungssuchenden mit dem OP-Ergebnis ist durchweg hoch, was die Bedeutung dieser Eingriffe unterstreicht.

Schlussfolgerung

Diese Übersichtsarbeit bietet einen umfassenden Überblick über die aktuellen chirurgischen Techniken für Brustoperationen bei Geschlechtsinkongruenz. Mit der zunehmenden Zahl von transidenten und non-binären Patienten steigt die Bedeutung klarer chirurgischer Leitlinien, um den hohen Ansprüchen seitens der Behandlungssuchen und teils komplexen anatomischen Herausforderungen gerecht zu werden. Die S2k-Leitlinie, entwickelt von Expert:innen verschiedener beteiligter Fachdisziplinen, unterstützt diesen Bedarf. Die hohe Zufriedenheit der Patient:innen mit den Operationsergebnissen betont die Relevanz dieser Eingriffe für die Verbesserung der Lebensqualität.

Abstract

Background

“Top surgery”, which refers to gender-affirming chest procedures, is one of the most common surgeries for individuals with gender incongruence (GI). These surgeries include breast augmentation or mastectomy and aim to align the physical appearance with gender identity. This review is based on the newly published German S2k guideline “Surgical Measures for Gender Incongruence” and offers a comprehensive overview of current breast surgery techniques and relevant literature.

Patients/Material and Methods

A literature analysis was conducted based on data from PubMed from 1973 to July 2024. The analysis included 122 studies on gender-affirming chest surgeries for individuals with GI. The core statements were extracted and summarized.

Results

Gender-affirming chest surgeries, including both breast augmentation and mastectomy, generally lead to significant improvements in the well-being of individuals. Breast augmentations often involve silicone implants or autologous fat grafting. Mastectomies for chest flattening aim to create a smooth, masculine-contoured or neutral chest while preserving nipple sensation. The choice of surgical technique largely depends on breast size, the degree of ptosis, and skin elasticity. Patient satisfaction with the surgical outcomes is consistently high, underscoring the importance of these procedures.

Conclusion

This review provides a comprehensive overview of current surgical techniques for chest surgeries in individuals with gender incongruence. With the growing number of transgender and non-binary patients, clear surgical guidelines are increasingly important to meet the high demands and address complex anatomical challenges. The new German S2k guideline, developed by German experts from various participating disciplines, supports this need. The high patient satisfaction with surgical outcomes underscores the significance of these procedures for improving quality of life.

Schlüsselwörter

Transsexualismus, Interdisziplinäre plastische Chirurgie - Brustchirurgie - Brust, Körperregion und Anatomie - Mastektomie

Keywords

Transgender - Top Surgery - gender-affirming surgery - chest masculinization - gender dysphoria - gender incongruence

Publication History

Received: 24 August 2024

Accepted: 03 March 2025

Article published online:
19 May 2025

• Literatur

• 1 Coleman E, Radix AE, Bouman WP. et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgender Heal 2022; 23: 1-259
• 2 AWMF S3-Leitlinie. Geschlechtsinkongruenz, Geschlechtsdysphorie und Trans-Gesundheit: Diagnostik, Beratung, Behandlung. 09102019 gültig bis 08102023 2020: Registernummer 138-001. Im Internet https://www.awmf.org/leitlinien/detail/ll/138-001.html
• 3 Statista. Anzahl der geschlechtsangleichenden Operationen in Deutschland von 2014 bis 2021. Statista [Internet]. 2023 [zitiert am 3. Februar 2025]; Verfügbar unter https://de.statista.com/infografik/27135/anzahl-der-geschlechtsangleichenden-operationen-in-deutschland/
• 4 Wright JD, Chen L, Suzuki Y. et al. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open 2023; 6: e2330348-e2330348
• 5 Schoffer AK, Bittner AK, Hess J. et al. Complications and satisfaction in transwomen receiving breast augmentation: short- and long-term outcomes. Arch Gynecol Obstet 2022; 305: 1517-1524
• 6 Alcon A, Wang E, Oliver-Allen H. et al. The Breast Response to Estrogenic Stimulation in Transwomen Classification: Evaluation of Breast Response to Estrogenic Stimulation in Transwomen. Ann Plast Surg 2021; 87: 402-408
• 7 Khan J, Schmidt RL, Spittal MJ. et al. Venous thrombotic risk in transgender women undergoing estrogen therapy: A systematic review and metaanalysis. Clin Chem 2019; 65: 57-66
• 8 Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child 1969; 44: 291-303
• 9 Bellinger CG, Goulian DG. Secondary surgery in transsexuals. Plast Reconstr Surg 1973; 51: 628-631
• 10 Ratnam SS, Lim SM. Augmentation mammoplasty for the male transsexual. Singapore Med J 1982; 23: 107-109 Im Internet https://pubmed.ncbi.nlm.nih.gov/7134998/ Stand: 20.09.2020
• 11 Kanhai RCJ, Hage JJ, Karim RB. et al Exceptional presenting conditions and outcome of augmentation mammaplasty in male-to-female transsexuals. Ann Plast Surg 1999; 43: 476-483 [25]
• 12 Nauta AC, Baltrusch KM, Heston AL. et al. Differences in Chest Measurements between the Cis-female and Trans-female Chest Exposed to Estrogen and Its Implications for Breast Augmentation. Plast Reconstr Surg – Glob Open 2019; 7
• 13 Coon D, Lee E, Fischer B. et al. Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results. Plast Reconstr Surg 2020; 145: 1343-1353
• 14 Salgarello M, Visconti G. Staying Out of Double-Bubble and Bottoming-Out Deformities in Dual-Plane Breast Augmentation: Anatomical and Clinical Study. Aesthetic Plast Surg 2017; 41: 999-1006
• 15 Fertsch S, Wolter A, Rancati A. et al. D-SUN Method to Prevent Double-Bubble Deformity in Broad Base Breasts with High-Rising Inframammary Fold. Aesthetic Plast Surg 2020;
• 16 Miller TJ, Wilson SC, Massie JP. et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open 2019; 21: 63-74
• 17 Basile FV, Basile AV, Basile AR. Striae distensae after breast augmentation. Aesthetic Plast Surg 2012; 36: 894-900
• 18 Manav S, Ayhan MS, Deniz E. et al. Capsular contracture around silicone miniimplants following bacterial contamination: an in vivo comparative experimental study between textured and polyurethane implants. J Plast Reconstr Aesthetic Surg 2020; 73: 1747-1757
• 19 Bayter-Marin JE, Cárdenas-Camarena L, Aguirre-Serrano H. et al. Understanding fatal fat embolism in gluteal lipoinjection: A review of the medical records and autopsy reports of 16 patients. Plast Reconstr Surg 2018; 142: 1198-1208
• 20 Gentile P, De Angelis B, Di Pietro V. et al. Gentle Is Better: The Original „Gentle Technique“ for Fat Placement in Breast Lipofilling. J Cutan Aesthet Surg 2018; 11: 120-126
• 21 Colebunders B, T’Sjoen G, Weyers S. et al. Hormonal and surgical treatment in trans-women with BRCA1 mutations: A controversial topic. J Sex Med 2014; 11: 2496-2499
• 22 Fakin RM, Zimmermann S, Kaye K. et al. Long-Term Outcomes in Breast Augmentation in Trans-Women: A 20-Year Experience. Aesthetic Surg J 2019; 39: 381-390
• 23 Raven LM, Guttman-Jones M, Muir CA. Hyperprolactinemia and association with prolactinoma in transwomen receiving gender affirming hormone treatment. Endocrine 2021; 72: 524-528
• 24 Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med 2011; 364: 1251-1257
• 25 Hartley RL, Stone JP, Temple-Oberle C. Breast cancer in transgender patients: A systematic review. Part 1: Male to female. Eur J Surg Oncol 2018; 44: 1455-1462
• 26 Kaplan J, Rohrich R. Breast implant illness: a topic in review. Gland Surg 2021; 10: 430-443
• 27 Zaveri S, Yao A, Schmidt H. Breast Implant-Associated Anaplastic Large Cell Lymphoma Following Gender Reassignment Surgery: A Review of Presentation, Management, and Outcomes in the Transgender Patient Population. Eur J breast Heal 2020; 16: 162-166
• 28 Nolan IT, Dy GW, Levitt N. Considerations in Gender-Affirming Surgery: Demographic Trends. Urol Clin North Am 2019; 46: 459-465
• 29 Wierckx K, Van de Peer F, Verhaeghe E. et al. Short- and Long-Term Clinical Skin Effects of Testosterone Treatment in Trans Men. J Sex Med 2014; 11: 222-229
• 30 Ammari T, Sluiter EC, Gast K. et al. Female-to-Male Gender-Affirming Chest Reconstruction Surgery. Aesthetic Surg J 2019; 39: 150-163
• 31 Lindsay WRN. Creation of a male chest in female transsexuals. Ann Plast Surg 1979; 3: 39-46
• 32 Kaczynski A, McKissock PK, Dubrow T. et al. Breast reduction in the male-to-female transsexual. Ann Plast Surg 1989; 23: 323-326
• 33 Wise TN. Transsexualism: a clinical approach to gender dysphoria. Med Trial Tech Q 1982; 29: 167-208 Im Internet http://www.ncbi.nlm.nih.gov/pubmed/6759840 Stand: 12.07.2020
• 34 Joris Hage J, Van Kesteren PJM. Chest-wall contouring in female-to-male transsexuals: Basic considerations and review of the literature. Plast Reconstr Surg 1995; 96: 386-391
• 35 Monstrey S, Selvaggi G, Ceulemans P. et al. Chest-wall contouring surgery in female-to-male transsexuals: A new algorithm. Plast Reconstr Surg 2008; 121: 849-859
• 36 Wolter A, Diedrichson J, Scholz T. et al. Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthet Surg 2015; 68: 184-191
• 37 Webster JP. Mastectomy for Gynecomastia Through a Semicircular Intra-areolar Incision. Ann Surg 1946; 124: 557-575 Im Internet http://www.ncbi.nlm.nih.gov/pubmed/17858862 Stand: 09.04.2020
• 38 Benelli L. A new periareolar mammaplasty: The „round block“ technique. Aesthetic Plast Surg 1990; 14: 93-100
• 39 Kornstein AN, Cinelli PB. Inferior pedicle reduction technique for larger forms of gynecomastia. Aesthetic Plast Surg 1992; 16: 331-335
• 40 East EG, Gast KM, Kuzon WM. et al. Clinicopathological findings in female-to-male gender-affirming breast surgery. Histopathology 2017; 71: 859-865
• 41 Timmermans FW, Ruyssinck L, Mokken SE. et al. An external validation of a novel predictive algorithm for male nipple areolar positioning: an improvement to current practice through a multicenter endeavor. J Plast Surg Hand Surg 2023; 57: 103-108
• 42 Timmermans FW, Elfering L, Smit JM. et al. Long-Term Changes in Free Nipple Graft Morphology and Patient-Reported Outcomes in Gender-Affirming Mastectomies. Aesthetic Plast Surg 2022; 46: 2174-2180
• 43 McTernan M, Yokoo K, Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg 2020; 84: S323-S328
• 44 Ferrin PC, Pua E, Isbester K. et al. Factors Affecting the Choice to Forgo Nipple Grafts in Gender-Affirming Chest Surgery. Ann Plast Surg 2024; 93: 189-193
• 45 Fledderus AC, Gout HA, Ogilvie AC. et al. Breast malignancy in female-to-male transsexuals: systematic review, case report, and recommendations for screening. Breast 2020; 53: 92-100
• 46 Wilson SC, Morrison SD, Anzai L. et al. Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes. Ann Plast Surg 2018; 80: 679-683
• 47 Atiyeh BS, Dibo SA, El Chafic AH. Determination of the nipple-areola complex position on the male thorax. Plast Reconstr Surg 2009; 123
• 48 Hassan B, Zeitouni F, Ascha M. et al. Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors. Cureus 2023; 15: e45948
• 49 Kääriäinen M, Salonen K, Helminen M. et al. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg 2017; 106: 74-79
• 50 Wolter A, Scholz T, Pluto N. et al. Subcutaneous mastectomy in female-to-male transsexuals: Optimizing perioperative and operative management in 8 years clinical experience. J Plast Reconstr Aesthetic Surg 2018; 71: 344-352
• 51 Keck M, Bosselmann K, Müller-Wittig S. et al. [Topical Application of Tranexamic Acid in Subcutaneous Mastectomy Wounds in Female-to-male Transgender Patients]. Handchir Mikrochir Plast Chir 2022; 54: 501-506
• 52 Edalatpour A, Seitz AJ, Warden AM. et al. Outcomes of enhanced recovery protocols and tranexamic acid on double-incision versus periareolar gender-affirming mastectomy: A retrospective study of postoperative outcomes. J Plast Reconstr Aesthetic Surg 2024; 88: 360-368
• 53 Berry MG, Curtis R, Davies D. Female-to-male transgender chest reconstruction: A large consecutive, single-surgeon experience. J Plast Reconstr Aesthetic Surg 2012; 65: 711-719
• 54 Robinson IS, Rifkin WJ, Kloer C. et al. Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?. Plast Reconstr Surg 2023; 151: 421-427
• 55 Garland K, Mullins E, Bercovitz RS. et al. Hemostatic considerations for gender affirming care. Thromb Res 2023; 230: 126-132
• 56 Arrington-Sanders R, Connell NT, Coon D. et al. Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review. Endocr Pract 2023; 29: 272-278
• 57 Das RK, Al Kassis S, Thayer WP. Hypertrophic scarring and scar revision in gender-affirming mastectomy: a systematic review. Arch Dermatol Res 2024; 316: 507
• 58 Perez-Alvarez IM, Zolper EG, Schwitzer J. et al. Incidence of Complications in Chest Wall Masculinization for the Obese Female-to-Male Transgender Population: A Case Series. WORLD J Plast Surg 2021; 10: 14-24
• 59 Yeung H, Kahn B, Ly BC. et al. Dermatologic Conditions in Transgender Populations. Endocrinol Metab Clin North Am 2019; 48: 429-440
• 60 Rifkin WJ, Robinson IS, Kloer C. et al. Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns. Plast Reconstr surgery Glob open 2022; 10: E4356
• 61 Van De Grift TC, Elfering L, Bouman MB. et al. Surgical indications and outcomes of mastectomy in transmen: A prospective study of technical and self-reported measures. Plast Reconstr Surg 2017; 140: 415E-424E
• 62 Tolstrup A, Zetner D, Rosenberg J. Outcome Measures in Gender-Confirming Chest Surgery: A Systematic Scoping Review. Aesthetic Plast Surg 2020; 44: 219-228
• 63 Rahmani B, Park JB, Adebagbo OD. et al. Complications after gender-affirming chest masculinization surgery do not impact patient satisfaction. J Plast Reconstr Aesthet Surg 2024; 95: 24-27